MEDICARE: DR. KEVIN THOMAS KING D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	19A16281	IL

General Provider Information

NPI Number	:	1588712723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN THOMAS KING D.D.S.

Provider Business Mailing Address
First Line	:	6217 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-3730
Country	:	US
Telephone Number	:	773-775-3663
Fax Number	:	773-775-8815

Provider Business Practice Location Address
First Line	:	6217 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-3730
Country	:	US
Telephone Number	:	773-775-3663
Fax Number	:	773-775-8815

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2007
Last Update Date	:	07/08/2007

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